Brave and angry – The creation and development of the International Planned Parenthood Federation (IPPF)

Abstract

This paper looks back on the developments in thinking from birth control, through voluntary family planning, to a comprehensive approach to sexual and reproductive health and rights (SRHR), and celebrates some of the key players in this evolution. It tells the story of the creation of the International Planned Parenthood Federation (IPPF) in 1952, and scrutinises how important this organisation was then and is now. It gives an idea of the efforts it took to reassemble initiatives around the world into one body, strong enough to foster the cause to the benefit of all. While IPPF was and still is a unique association, it has increased its partnerships and works together with a multitude of organisations active in the field of SRHR. In the current political context joint efforts are still needed to protect the universally recognised human right of people to decide freely and responsibly on the number and spacing of their children, and their access to adequate education and information.

Keywords:

• International grass roots movement
• Family Planning
• Sexuality education
• Sharing of experience
• Shaping the agenda

THE EARLY DAYS

Although the big breakthrough in family planning (FP) and the development of modern contraceptives took place in the 20th century, the desire to find ways to control fertility goes back much further in history. Thomas Robert Malthus (1766–1835), an English clergyman, argued as long ago as 1798 that the population would increase faster than the world would be able to feed it and urged that this growth be controlled¹. The first international Malthusian conference took place in London in 1881 but did not elicit the desired reaction from the medical professionals. The Malthusians were in general not supported in their belief that population growth was the cause of all problems in the world.

By 1922, at the time of their Fifth International Conference, public opinion had shifted to embrace emancipation and social change. The Malthusian League grew in size and gained in popularity. However, not all new members were willing to accept Malthusian theory or agreed with the rather conservative policies and activities. This led to the creation of new organisations with ideas of their own and new pioneers stood up; all would play extremely important roles in the years to come. In the United Kingdom, Dr Marie Stopes created the Marie Stopes clinics² and in the US Margaret Sanger would play a prominent international role throughout her life³. In the course of time there were many others who joined and worked together to build a real movement which would ultimately result in 1952 in the creation of the International Planned Parenthood Federation (IPPF).

In the early days people had many different opinions on why FP was important. There were those who were interested in eugenics; some were strong believers that FP could play a role in the emancipation of women and therefore would promote social progress; others were merely interested in birth control as a means of reducing maternal and child mortality, and others still considered it would benefit the individual, the family, and the nation.

Throughout the history of the family planning movement, these different opinions would play a role in how FP was organised at national level. Between the First and Second World Wars a series of international conferences were held and different organisations were created, like the World League for Sexual Reform (WLSR). WLSR brought together many well-known intellectuals who talked about sexual relationships and free love, companionate marriage (in which spouses believe in the equality of men and women and believe their roles in marriage are interchangeable), masturbation, homosexuality, and prostitution. They brought to the floor a view on sexuality which went far beyond the FP agenda and which would still today be considered progressive.

At the Sixth International Malthusian Conference held in New York in 1925, a new association saw the light: the International Federation of Birth Control Leagues and, in 1927, the First World Population Conference was convened in Geneva. Margaret Sanger and her group made an enormous effort and invested money into these conferences which brought together the world's leading demographers, scientists, sociologists and physicians. However, not much progress was made at these meetings because of the controversy on linking birth control with population growth. It is interesting to note that even at that time more than one was concerned about the number of people on the earth and how they would be fed. They would probably have been utterly shocked to learn that the world would soon count 6.5 billion. Indeed, it had taken 123 years for the world population to increase from (an estimated) one billion in 1804, to two billion in 1927, but less than 80 years to more than treble thereafter. The issue of birth control and population growth throughout history played a major role in the debates and caused heated discussions between demographers and the ‘family planners’. The latter indeed have different starting points: whereas demographers focus on population numbers, the others look at human rights and the development of the individual.

It is only in 1930, at the Seventh International Birth Control Conference, that participants of 12 countries shared their experience at the national level and came to some common understanding about why birth control was important. It was decided that FP was an essential part of public health and an aspect of preventive medicine that should be given due consideration; that the knowledge on contraception was the best way of fighting abortion; and that instruction in techniques of birth control should be part of all medical curricula. This was the programme of the future and many of those who were at that meeting would later become the founders of IPPF.

The legal conditions and political dynamics were very different in the US compared to, for instance, the UK. In the US, birth control and contraceptives were illegal and it took the courage and activism of people like Margaret Sanger and many others, to challenge the State. For having distributed leaflets on the streets with information on birth control several of them ended up in jail. When they were released they just started all over again and never gave up. In contrast, in the UK, opposition to family planning was less extreme than in the US and, since 1926, the provision of information on contraception was no longer restricted⁴. Marie Stopes could open the first FP clinics in London in 1921. In other parts of the world, birth control was often severely regulated. So, for instance, in France and Belgium, birth control was illegal until the 1960s and the 1970s, respectively. In countries where the legal status of contraception was not clearly defined and regulated, concerns arose about the legality of the work of service providers and activists.

Birth control was not only a concern for Europeans and Americans; India and other Asian countries had their own pioneers. The All-India Women's Conference was one of the leading groups that invited representatives of European and American organisations to come and discuss birth control at their meetings. Numerous exchange visits took place, and Margaret Sanger and others visited local clinics in many countries. In Asia, India took the lead; the first birth control clinics in that country became operational in 1930.

The Netherlands were the first country in the world where, as early as 1890, people had access to a real birth control clinic. It had been opened in Amsterdam by Dr Aletta Jacobs, the first woman ever to become medically qualified in Holland⁵. She promoted the use of the diaphragm which had been developed in the early 1880s by Dr Wilhelm Mensinga, a Dutch-born physician who had a private practice in Trittau, Germany. Because contraception was taboo, Mensinga had published his brochure entitled ‘Das Pessarium Occlusivum’, in 1884, under a pseudonym (Dr Carl Hasse)⁶. The diaphragm was so widely used by Dutch women that it became known as the ‘Dutch cap’.

POST WORLD WAR II DEVELOPMENTS

The outbreak of the war delayed or stopped many of the activities because the FP providers had moved and contraceptives were no longer available. After the war the future looked bleak. The international contacts were lost and in some countries the whole system had been swept away.

It was Sweden that took the lead in the post-war era. Mrs Elise Ottesen-Jensen (also known as Ottar) had founded in 1933 the Riksförbundet för Sexuell Upplysning (RFSU), which became later a founding member of IPPF and is still operating under the same name today. RFSU was very active in advocating a new legislation and a change in public opinion. The association presented radical ideas with regard to sexual education and worked with trade unions, political organisations and groups involved in educating the public. The approach was rather unique and was quickly accepted by the general public. The motto of RFSU was ‘Sex education for all’ and Elise Ottesen-Jensen brought the message with energy to universities, schools, military camps and homes. The association became an example for the government and soon received the full approval of the Swedish government for the actions it undertook.

RFSU was to hold its annual conference in August 1946 and Elise Ottesen-Jensen extended an international invitation to everybody interested in sex education and FP. At that conference many expressed the need for a new kind of international organisation which would not duplicate the work of others but rather form a link for those who were working at the national level. This was a very significant step; the international association which was eventually formed would prove to have an even greater value and influence than participants were aware of at that time.

Several international conferences were held in the course of the following years. Each of these was a step forward towards a mutual understanding of what a new international organisation should accomplish. This was very important because opinions on what were key issues differed greatly. The Swedes and the Dutch applied a sex education approach; the Americans were merely interested in world population problems, and the Brits in their FP clinics. To cover all these aspects the denomination ‘Planned Parenthood’ was chosen as a compromise.

In 1949 the Family Planning Association of India (FPAI) was established and its activity immediately exceeded all expectations. Branches were created all over the country and the government did its share. There were no conservative reactions in India as there were in the rest of the world and this allowed the development of FP clinics with government support. Because of this favourable environment it was decided to hold the next international conference in India. This turned out to be a fortunate initiative as a great number of people agreed to sponsor the conference. These were not only the FP champions but celebrities from other walks of life, among whom Albert Einstein and the Indian Prime Minister Jawaharlal Nehru to name just two.

THE CREATION OF THE INTERNATIONAL PLANNED PARENTHOOD FEDERATION

In New Delhi, on 29 November 1952, the IPPF came into existence under the joint Presidency of Margaret Sanger and Lady Rama Rau from India. The founding countries were India, the United States of America, the United Kingdom, Sweden, the Netherlands, West-Germany, Singapore and Hong Kong⁷ , ⁸. At the same time the Population Council was established in the United States; its aim would be to undertake the scientific study of population.

From the beginning IPPF decided to operate with Regions and Regional Offices. South and South-East Asia would be served from India; Europe had its regional office in London, and North America operated from New York. It was only much later, when IPPF had expanded, that the regions were reorganised into the format they still have today, with Regions and Regional Offices being: Africa (Nairobi); Western Hemisphere (New York); Arab World (Tunis); South Asia (New Delhi); South-east Asia and Oceania (Kuala Lumpur), and Europe and Central Asia (Brussels).

Three main points were raised as of particular concern for the movement: the danger of rapidly expanding population and limited natural resources; the need for research on new methods of contraception, and the increasing rates of abortion. It needs to be noted that in 1952 contraceptive methods were still those of the 1880s: cervical caps, condoms, spermicides, and pessaries. Therefore the development of modern contraceptives was a major objective and the subsequent conferences all covered progress in this area.

The principles that are still steering the work of IPPF today have their roots in the earliest phase of its existence. One of these is that any activity of IPPF should always be in response to a demand from within a country. With this principle it was recognised from the start that countries and regions differed and that it was the local people who could provide the best response to local needs. The role of IPPF was – and still is – to facilitate learning and the exchange of experience, and to promote a favourable environment for FP and sexual and reproductive health and rights (SRHR).

IPPF'S ROLE IN THE DEVELOPMENT OF MODERN CONTRACEPTIVES

At the time of the World Population Conference of 1954 there was excitement about the scientific advances being made in relation to contraceptives. Again it was Margaret Sanger who took a particular interest in the development of oral contraceptives (OCs). She arranged through the Planned Parenthood Federation of America for a small grant to Dr Gregory G. Pincus and his colleagues to help them with their research on progestational compounds.

IPPF decided that it needed full autonomy in order for its programmes to be successful. It therefore created a Medical Committee to assist IPPF in stimulating and following medical progress in the domain of FP. Both the name and the format of the Committee changed over the years and its functions expanded. In 1959, under the chairmanship of Dr Alan F. Guttmacher, its mandate was agreed upon as follows:

To collect, analyze and circulate information regarding relevant activities …  to set standards for clinics when requested; to maintain a testing sub-committee whose functions shall be to obtain the full formulae of new contraceptive products and to arrange for them to be tested for harmlessness, spermicidal efficiency, durability and acceptability with the ultimate aim of establishing an international list of accepted products.

In 1963 the functions were further expanded:

the duties of the Medical Committee shall be to establish medical policy for the IPPF and advise the Governing body on all medical matters; to co-ordinate and advise on the medical work of the Regions; [ … ]; to establish medical standards for all services related to family planning; to arrange for clinical trials and the testing of contraceptive materials and appliances; to work with other agencies as appropriate; to be responsible for the medical aspects of all IPPF publications; … 

Several sub-committees were constituted to implement all these activities:

1. The Evaluation Sub-Committee (established in 1955) had the objective of reaching an international agreement on tests and standards for contraceptives and for the evaluation of new methods. An agreement was reached on tests for spermicidal efficiency, foaming capacity, local harmlessness, and stability of storage of spermicides. The findings were accepted internationally.

2. The Field Trials Sub-Committee (1959) was to establish standards for field trials with Dr Christopher Tietze as convener.

3. A Rubber Group (1960), headed by Dr David Edwards was to carry out tests on rubber appliances.

4. The Specialist Group on Oral Contraceptives (1962) under the chairmanship of Drs Gregory Pincus and G. I. M. Swyer was to advise on the administration of OCs and their side effects.

5. The Intrauterine Devices Group was headed by Professor Howard C. Taylor.

6. During all that time the groups published their findings and distributed them widely. In 1965 the structure of these groups was simplified and a new periodical was started, the Medical Bulletin, which still exists.

Today, the IPPF continues to be advised and assisted in its medical work by the International Medical Advisory Panel (IMAP) which is composed of independent experts. The IMAP Statements are guiding IPPF's programming of its activities. The IPPF publications on Medical and Service Delivery Guidelines (available also in Russian) and on Quality of Care are very often downloaded by service providers all over the world. The Directory of Hormonal Contraceptives provides guidance in finding the right brand with the appropriate composition all over the world.

In the meantime, the Family Planning Federation of Japan, founded in 1953, provided for the first time a membership for IPPF that was composed of a group of FP organisations that had united under the form of a Federation. Japan was a leading country and, as in India, the government was taking a keen interest in FP. At the IPPF Fifth International Conference held in Tokyo in 1955, two contraceptive methods were discussed that changed the whole prospect of fertility control. Japanese doctors discussed the revival of the IUD, an old method that was nearly forgotten in western society but that, in Japan, Teneri Takeo Ota and Atsumi Ishihama had continued to use successfully⁹. At the same time Dr Gregory Pincus made history when he read a paper explaining his work on the inhibition of ovulation by progestins and other steroids. He stressed that he was presenting work in progress but nevertheless he would become known as ‘Pincus of the Pill’¹⁰. It had become clear that acceptance of any method would involve extensive trials and that the trials would require to be very thoroughly designed. IPPF was asked to step in and to help reach an agreement on some critical, technical aspects of fertility control. In 1959, the IPPF Research Committee was formed; Dr Gregory Pincus was one of its most eminent members.

While Dr Pincus was still cautious in 1955, at the Sixth International Conference held in New Delhi, in 1959, he was able to present the striking results of a field trial in which 830 women had been studied over a period of 622 woman years. A 96% reduction in the pregnancy rate had been achieved¹⁰. The Vice-President of India, Dr Sarvepelli Radhakrishnan, addressing the final session of the IPPF sixth International Conference, conveyed a liberating message:

It is not right to think that the sex instinct and the reproductive instinct, though they go together, must always go together. Sex is the expression of love as well as the means of procreation. These two things may be distinguished and it is not right to say that you must suppress the sex instincts because you don't wish to have a child. Repression is not the remedy.

In 1960 the US Food and Drug Administration (FDA) approved the oral contraceptive pill and the Planned Parenthood Federation of America (PPFA) decided to offer it in clinics through its 100 affiliates. One year later the Pill went on sale in the UK. In 1963 the International Council of Women passed a resolution urging world-wide education in family planning.

IPPF and its members actively promoted the use of OCs by providing these directly in their FP clinics. They also trained general practitioners and advocated that contraceptives be taken into consideration in the public health systems and be made available at a low cost or for free.

IPPF AROUND THE WORLD

Development was slow in Africa and the Middle East as most of the groundwork was done through visits that aimed at stimulating and encouraging the practice of birth control, and at opening people's minds to sexual and reproductive behaviours that were unfamiliar to them. In large areas of Africa, because of their culture, people were more concerned about being infertile than about controlling fertility. Child mortality and sexually-transmitted infections (before the HIV pandemic!) kept population growth down.

A first FP association was established in South Africa in 1953, followed by Kenya. In December 1967, IPPF organised a four-day seminar in Nairobi that was attended by more than 100 delegates from 16 Sub-Saharan countries; the ‘Role of Family Planning in African Development’ was intensively studied. In 1971, under the leadership of Dr Fred Sai, a separate IPPF Africa Region was founded. Progress followed with a number of governments adopting FP andpopulation policies. The greatest success in recent years, to which the IPPF Africa Regional Office has greatly contributed, was the adoption of the Maputo Plan of Action. It is the first, African owned document – approved by all African leaders – in which sexual and reproductive health and rights (SRHR), including the right to safe abortion, are prominently included¹¹.

IPPF affiliates in Japan, South Korea and Hong Kong were the first to form the East & South-East and Oceania Region. Population growth was certainly an issue in this region and the diverse cultural and religious barriers, whether Muslim, Catholic or Buddhist, needed to be dealt with patiently and sensitively. By 1987 the Region counted affiliates from 13 countries.

India, Pakistan and Sri Lanka (then Ceylon) were among the most active countries in the South Asia Region. By the end of 1963 the Family Planning Association of India had 30 branches and almost 200 clinics. They were experimenting with mobile clinics and, in October 1962, the Minister opened a new FP training centre at Hyderabad which offered a course for family welfare workers.

When IPPF was established and the discussions on the regions took place the situation in the ‘Americas’ was quite different from that in other regions, and this is still the case. In 1954 the Western Hemisphere Region (WHR) was created by prominent representatives of the FP movements of Barbados, Bermuda, Canada, Haiti, Jamaica, Mexico, Puerto Rico, and the United States. From then on the Region made contacts with other countries in the Caribbean but vast areas of Central and South America remained for the most part untouched. Much progress was made when the medical and scientific advances of the late 1950s and early 1960s cast a new light on how to approach fertility control. Nowhere was the change as significant as in Latin America. The issue of population had long been taboo but it came to the surface after the IPPF/WHR conference in Puerto Rico in 1964. Country leaders began to acknowledge that the problems brought up at and the proceedings of the conference, which were widely publicised throughout Central and South America, provided not only food for thought but also solutions; indeed, one article dealt with the IUD and its possibilities. The editorial board of Visión was chaired by Dr Alberto Lleras Camargo, a former President of Colombia who became subsequently the Chairman of the First Pan American Assembly on Population which convened in Colombia in 1965. This important meeting was attended by 75 opinion leaders from all over the continent who were active in business, church, communication, education, labour, law, governance and medicine. The recommendations of the Assembly were far-reaching and called for each government to develop national population policies. Nowadays, the IPPF/WHR is a region with some of IPPF's strongest member associations in Latin America. PPFA is still the largest provider and strongest advocate for SRHR in the US.

While, in the East, authorities and the medical profession did their utmost to educate the population but found that people still lacked understanding of FP and did not want to co-operate, Western Europe experienced the reverse. There, the population was being frustrated by the negative attitudes of both the authorities and the medical profession. Another major problem throughout Europe was abortion. However, by 1960, every European country, except for Austria, Ireland, Portugal and Spain, had a voluntary FP association or a government service. More than in any other region, the Europeans stressed the personal and social aspects of fertility control, and FP became recognised as a human right. Much later, in 1994, it was the Europe Region that led IPPF in accepting the IPPF Charter on Sexual and Reproductive Rights. This document was based on internationally accepted human rights instruments and it became a means of monitoring sexual and reproductive health violations¹².

By 2008, under the initiative of the IPPF Western Hemisphere Region, IPPF took the human rights agenda one step further and published Sexual Rights: an IPPF Declaration ¹³.

The Europe Region was for a long time composed of Western European countries although there were contacts with Yugoslavia, Russia and Poland. It is only after the fall of the Berlin Wall that IPPF extended its membership to include all countries of Central and Eastern Europe. Soon thereafter IPPF established FP associations in Uzbekistan, Tajikistan, Kyrgyzstan, and Kazakhstan. Including almost all countries of the Former Soviet Union significantly changed the size of the region as well as its dynamic. From then on the region was composed of rich countries, most of which were donors to IPPF, and some of the poorest countries, with extremely bad indicators for contraceptive use and maternal mortality.

THE UNITED NATIONS WORLD CONFERENCES

Even before the creation of IPPF there was a keen interest of the FP champions to engage with the United Nations (UN) bodies.

In 1946 the UN Population Commission was created; it took quite some time to develop programmes and to initiate basic demographic research. In 1948 UNESCO proposed to the Population Commission that they should organise a Conference on World Population Problems as the matter had not been discussed since the last conference convened by the International Union for the Scientific Study of Population (IUSSP) in 1937.

The first United Nations World Population Conference took place in Rome in 1954; more would follow in Belgrade (1964), Bucharest (1974), and Mexico (1984). These UN Conferences focused on the issue of population growth and were merely steered by demographers. Medical professionals were not in attendance and FP was not seen as something important in that context.

The members of IPPF were in the first place service providers but IPPF had already from the beginning the strength to mobilise its members around the world to make significant changes in global decision making. One very important action started right after the Belgrade World Population Conference, which showed that IPPF was also a human rights organisation. The 1948 Universal Declaration of Human Rights did not mention population and family planning. After the Bucharest meeting IPPF decided to organise a Human Rights Year programme in the run up to the International Conference on Human Rights to be held in Tehran in 1968, which was to mark the 20th anniversary of the Universal Declaration on Human Rights. A human rights kit was issued and a ten-minute film ‘A Threat or a Promise?’ was shown on television, and the IPPF monthly News produced a special supplement. The Family Planning Associations everywhere supported this effort. Political leaders were approached and, prior to the Tehran meeting, IPPF convened a consultation of non-governmental organisations to discuss FP as a human right. Later the UN General Assembly approved without dissent a resolution drawing attention to the link between population growth and human rights which stated ‘that parents had the basic human right to decide freely and responsibly on the number and spacing of their children, and a right to adequate education and information’.

Until then everything was going in the right direction, and more and more governmental support was obtained for the issue of FP. In 1973, the US Supreme Court legalised abortion in Roe v. Wade ¹⁴. But there was soon organised opposition to that decision. An amendment tabled by Senator Jesse Helms banned the use of foreign aid funds for abortion. This amendment would play for ever a significant role in IPPF's funding relationship with the US: it made IPPF's room for manoeuvre dependent on whether the US President was a Republican or a Democrat.

Since its inception IPPF recognised the political importance of the United Nations, and it tried to obtain consultative status with the UN's Economic and Social Council (ECOSOC), which is responsible for facilitating international cooperation in the domain of economic and social issues. This initially met with considerable aversion and suspicion, and it was only in 1964 that the Federation was granted the lowest level of Consultative Status. In 1969 the status was raised to Category II and finally, in 1973, ECOSOC granted IPPF Category I status, recognising that IPPF was concerned with most of the activities of the ECOSOC and that IPPF had made important contributions to the achievement of the objectives of the United Nations. Its enhanced status allowed IPPF to play a much more significant role at the forthcoming UN meetings and conferences.

In the 1990s four important UN conferences were held: the World Conference on Human Rights (Vienna, 1993), the International Conference on Population and Development (ICPD, Cairo, 1994), the World Summit on Social Development (Copenhagen, March 1995), and the Fourth World Conference on Women (Beijing, September 1995). The governments that were represented at those meetings set new directions for the future: there was a clear shift in the global agenda towards a focus on the individual person rather than the latter just being part of a group or society.

Three years of preparation preceded ICPD; the IPPF members played a significant role in their countries by bringing together civil society and organising joint actions towards their governments. The Conference was chaired by IPPF President Dr Fred Sai. Its essential achievement consisted of having reached an agreement on the need for ‘universal access to reproductive health by 2015’. A year later the Fourth Women's Conference agreed that ‘the human rights of women include their right to have control over and decide freely and responsibly on matters related to their sexuality’. This was a huge victory for the 1500 non-governmental organisations (NGOs) present, among them a broad range of women's associations, IPPF and its members.

Later, in 2000, the international community agreed on the Millennium Development Goals (MDGs) which try to set targets in eight different areas among which MDG 5 is related to maternal mortality. MDG 5b has been included later (not without strong advocacy efforts) and addresses universal access to reproductive health; MDG 6 is on combating HIV/AIDS. These three ‘health MDGs’ are very important for the world as a whole but it needs to be noted, not surprisingly, that MDG 5 and 5b are lagging behind in their implementation. There are lots of explanations for this but the bottom line is that many governments are still not valuing women's lives. The mere fact that these areas are still neglected is proof that political will is lacking to find solutions to improve women's lives all over the world. By now everybody knows perfectly what needs to be done to solve the unmet need for FP and reduce maternal and child mortality; for the prevention and treatment of HIV, and for the provision of information and education. One not only knows what needs to be done but also what it would cost to achieve the goals, and this is far less than what most countries are spending, for instance, on defence and war.

The coming years will be crucial with regard to the way governments will fulfil their commitments: the timeline of the Programme of Action of ICPD is now very near and the objectives are far from having been achieved. A hopeful sign is that there is recognition that reducing maternal mortality and achieving universal access to reproductive health are the MDGs most lagging behind and that FP is crucial to achieve those goals. This definitely brings birth control as such again to the forefront of political debates; hopefully this will lead to political commitments.

SEX AND POLITICS

This subtitle is borrowed from the Norwegian member of IPPF that recently changed its name to Sex and Politics. This illustrates how much IPPF's and many other organisations' core business is still influenced by the stand politicians worldwide take on this issue. There is probably no other area of life throughout history that has caused such permanent controversy. In every country the progress made has been due to the engagement and efforts of individuals, very often medical doctors, who were convinced, committed, brave and angry enough to put their reputation and even their lives in jeopardy. In a number of countries, men and women dared to face prosecution and imprisonment because of their strong belief in the cause they were and still are defending¹⁵ , ¹⁶.

Throughout their existence FP associations faced opposition. The introduction of OCs, later that of the emergency contraceptive pill and, still later, of medical abortion, led to serious conflicts with political and religious authorities. The stand of the Roman Catholic Church against artificial methods of contraception had over time less effect on Catholic countries like Italy and Spain but is still today influencing much the behaviour of Catholics in Latin America and Africa. In the sixties, access to OCs was in many countries limited to married couples. The fact that young people engage in sexual activities and may need to prevent unintended pregnancies is still a controversial issue in many countries around the globe. IPPF strives to make contraceptives available, affordable and accessible for everyone, including the poor and those who are marginalised. Investment from governments and donor communities has dropped significantly over the years, often in favour of investments in HIV/AIDS treatment. This has not helped to meet the demand of women and men wanting to control their fertility. In the European Region the former communist countries are still showing a very low uptake of modern contraceptives as abortion has been legal for decades and used as the accepted FP method. A combination of aversion against ‘Western’ methods, high suspicion towards hormonal contraceptives, and the fact that abortion is more lucrative for medical practitioners, means that increasing the prevalence of the use of hormonal and intrauterine contraceptives is still a major struggle. It is good to remember some examples of how politics influenced FP and later the more comprehensive approach to SRHR.

• In 1873, in the US, the Obscenity statute, also known as the ‘Comstock bill’, was passed which made the dissemination of information on birth control illegal. The regulation was named after Anthony Comstock, a fanatical crusader against anything that related to sexuality. The movements engaged in the promotion of contraceptive means and methods worked in the illegality and continued to push for change. It was not until 1936 that birth control was more or less freed by the US Court of Appeals through the settlement of a test case³ , ⁴.

• In Belgium providing information on contraceptives was illegal until 1973 and abortion was strictly prohibited until 1990. However, access to contraception as well as to safe abortion (with regard to the latter from the mid-1970s onwards) was not denied to people seeking either, as high quality service was provided at low cost for the clients in clinics whose operations were completely illegal at that time. Medical doctors and civil society groups (FP centres and women's movements) joined up to force change.

• The Vatican has constructed strange but strong alliances at UN meetings and beyond to limit reproductive health care because it includes the provision of abortion (where legal), to which the Church is opposed.

• In 1973 the Irish Supreme Court ruled that the law restricting the import of contraceptives was unconstitutional. Seven years later and after enormous advocacy efforts, the new Family Planning Act granted the Irish FPA licence to provide contraceptive information and services but did not allow it to sell contraceptives; that interdict still stands. In 1991 the FPA was prosecuted and fined for setting up a condom kiosk at the Virgin Megastore in Dublin but, only one year later, it succeeded in opening the first FP clinic in a shopping mall in the centre of Dublin. Ireland is one of the very few countries in Europe were abortion is still illegal.

• In 1974 the Argentinean government banned the promotion of contraception, and FP centres, including those of the FPA, were closed. It is only in 1977, after persistent lobbying, that the FPA could resume contraceptive services in some hospitals. In 1984 the FPA's headquarters suffered a bomb attack for which ultra-conservative groups, opposed to FP, were responsible. This terrorist act provoked widespread public support for the work of the FPA.

Yet, from the beginning there were also champions of FP in the political arena. In the UK, since the early 1930s, the health authorities at national and local level were stimulated by the Ministry of Health to develop birth control services for married women. This helped the Family Planning Association to develop at a time when, at the international level, the movement was still in its infancy. In 1948 the FPA had 63 clinics with well trained staff. The Marie Stopes network had two private clinics and contraceptive advice on medical grounds was given at 200 local authority clinics.

The governments of The Netherlands, Sweden, India and Japan were among the first to acknowledge the importance of FP and to embrace the work of the pioneers.

FAMILY PLANNING IN THE 21ST CENTURY

Everybody will agree that much has changed over all these years. IPPF is far from being the only NGO active in the field although it still has its specific features. European-based associations like Marie Stopes International (UK); Deutsche Stiftüng Weltbevorkerung (DSW); World Population Foundation (The Netherlands); Equilibres et Populations (France); many of the Nordic members of IPPF and many others are conducting programmes in the South, assisting a multitude of grass roots organisations – not only active in FP but also in women's and youths' associations. They form a solid group of European advocates who can negotiate with their own governments and the European Commission for a global implementation of SRHR.

In many Western European countries the FP associations handed over their clinics to the public health system where trained general practitioners provide FP and other reproductive health services. In countries where this shift proved successful, FP centres have changed their roles to centres of expertise and watchdogs for government policies and practice.

SRHR play a pivotal role in women's lives and development in general. This has led all actors in this field to invest a lot in networking and forming alliances, for instance, with other NGOs, UN agencies, and professional groups like the European Society of Contraception and Reproductive Health. These alliances are increasingly important in a world where conservative voices are gaining ground in some countries, where the right to safe and legal abortion is still questioned, where the sexuality of young people is still contested, and where sexual rights are still violated.

Declaration of interest: The author is Regional Director of the IPPF European Network. The author alone is responsible for the writing and the content of this paper. She acknowledges the editorial assistance provided by Bayer Schering Pharma. The author did not receive, nor does she expect to receive any payment for this contribution.